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Cervical Incompetence

Uterus Cervical Os Incompetent

Cervical incompetence, often termed cervical insufficiency, describes the inability of the cervix to maintain its function during the second and early third trimester, resulting in miscarriage or premature birth. Various conditions and iatrogenic causes (drugs, surgery) have shown to play a role in the pathogenesis of this condition. Clinical criteria, information regarding previous pregnancies and transvaginal ultrasonography are necessary during the diagnostic workup.


Presentation

Under physiological circumstances, the cervix possesses a crucial role in maintaining the fetus within the uterine cavity throughout the entire pregnancy, but in the setting of cervical incompetence, defined as a painless dilation and shortening of the cervix during the second trimester, the cervix is unable to perform its respective function [1] [2]. As a result, the expulsion of a live fetus during the second (or sometimes third) semester is the main clinical presentation of cervical incompetence, frequently resulting in miscarriage or sometimes in premature birth [3] [4] [5] [6]. The pathogenesis is yet to be revealed, but several risk factors have been established. Firstly, a significant ethnic predisposition toward African-American women is observed when compared to Caucasian women [6]. Secondly, several conditions are associated with an increased risk for cervical incompetence, including polycystic ovarian syndrome (PCOS), use of diethylstilbestrol (DES), previous surgery (termination of pregnancy, repeated cervical dilation, cone biopsy, and several other procedures) or trauma (during vaginal or cesarean delivery), as well as Ehlers-Danlos syndrome and uterine abnormalities [1] [3] [4] [7]. Cervical incompetence is completely asymptomatic in the majority of cases prior to sudden fetal expulsion, while vaginal spotting or bleeding, abdominal or lower back pain, and discharge are seen in some women prior to the event [4].

HELLP Syndrome
  • Two women required delivery before the onset of labor due to severe intrauterine growth restriction and one due to HELLP syndrome. These were excluded from further analysis.[ncbi.nlm.nih.gov]
Italian
  • [Article in English, Italian] Author information 1 Istituto Radiologia, Università Cattolica del S. Cuore, Policlinico A. Gemelli, Roma, Italy.[ncbi.nlm.nih.gov]
Anger
  • It is important to bear in mind that some clinical terms can cause great distress and even anger. The terms "blighted ovum" and "cervical incompetence" both imply blame. Cervical incompetence is better described as cervical weakness.[en.wikipedia.org]
Forgetful
  • I will never forget my son, he was my first born and I will always love him.[change.org]
  • We are very much in love with our little angel, but we will never forget our losses. We are considering trying to become pregnant again when Leah reaches a year. I will have to be bedridden, and have the circlage done, so it won't be easy.[sids-network.org]
Screaming
  • Then I had the worst pain ever, as I screamed my partner went to get the midwife who performed and an extremely painful internal exam and looked at me worryingly and said my membranes were bulging, she rushed me into a wheelchair saying I did not have[change.org]

Workup

Various reports from different parts of the world have emphasized the markedly increased rates of cervical incompetence than previously anticipated [5] [7]. Thus, this condition is hypothesized to be a rather important cause of premature delivery, but of miscarriage and fetal loss as well, which is why the diagnosis should be made as early is possible. A history of repeated pregnancy loss or preterm births is one of the first and most important elements that could be identified during history taking [2]. Secondly, the presence of any of the mentioned risk factors is necessary during workup, suggesting that a thoroughly obtained patient history is a vital step in order to raise clinical suspicion toward cervical incompetence, especially because an asymptomatic course is seen in almost all women. On the other hand, transvaginal ultrasonography has shown to be of pivotal benefit in predicting the ability of the cervix to maintain normal pregnancy [2] [4]. Studies indicate that preterm birth or fetal expulsion is much higher if cervical shortening ≤15 mm and its dilation is observed, while protrusion of fetal membranes into the cervical canal might also be suggestive of cervical incompetence [2] [4]. In addition, fetal fibronectin (fFN), and interleukin-6 in amniotic fluid are mentioned by certain authors as potentially useful markers in predicting preterm delivery [2]. However, the information obtained during history taking remain crucial for the diagnosis of cervical incompetence, meaning that physicians must maintain a high index of suspicion in women with previous preterm deliveries and miscarriages.

Treatment

  • There was no other serious complication after treatment. Nowadays, there is still no established method to diagnose cervical incompetence in pregnancy. Treatment is usually based on past obstetric history.[ncbi.nlm.nih.gov]
  • Abstract In the early 1950s, when treatment of cervical incompetence was first described, diagnosis seemed relatively simple and management favorable, but after more than 35 years of trying multiple variations of procedures and treatment regimens, no[ncbi.nlm.nih.gov]
  • This study aimed to evaluate the effectiveness and safety of cervical cerclage and vaginal progesterone in the treatment of cervical incompetence with/without PTB history.[ncbi.nlm.nih.gov]
  • Perioperative complications and obstetric outcomes were compared between LCC and TVC treatment groups. RESULTS: No perioperative complications occurred during LCC treatment. Of the 19 LCC patients, 15 (78.9%) became pregnant during the study period.[ncbi.nlm.nih.gov]
  • Abstract In this work, we have been studying the effects of Progesterone treatment on the outcome of pregnancy and its influence on the newborn, in a group of women who have undergone cerclage as a treatment of cervical insufficiency, in comparison with[ncbi.nlm.nih.gov]

Prognosis

  • Cervical incompetence is the frequent cause of abortion in the second trimester and premature delivery, with adverse fetal prognosis. Usually, three causative factors are considered: traumatic, constitutional, dysfunctional.[ncbi.nlm.nih.gov]
  • Sonographic determination of the residual closed length of the cervix may be measured if there is: known complicating pre-term premature rupture of membranes known hourglass type membranes active vaginal bleeding Treatment and prognosis Management options[radiopaedia.org]
  • In this innovative one-page format, you can review topics such as etiology/pathophysiology, differential diagnosis, presentation, diagnosis/evaluation, treatment options, and prognosis/complications for 126 topics.[books.google.com]
  • Minoru Mitani, Yoshio Matsuda, Erina Ono, Yoshika Akizawa and Hiroaki Ohta, Prognosis in cervical insufficiency at less than 32 weeks of gestation, European Journal of Obstetrics & Gynecology and Reproductive Biology, 125, 1, (34), (2006).[doi.org]

Etiology

  • In most instances cervical incompetence is the result of previous obstetric or gynecologic trauma; a congenital etiology is unusual.[ncbi.nlm.nih.gov]
  • However, the etiology and diagnostic method have still not been established.[ncbi.nlm.nih.gov]
  • Studying the etiology of the UCI requires a specific approach adequate for this highly heterogenous syndrome. Oxidative status disorders are associated with various pathologies, including pregnancy complications.[ncbi.nlm.nih.gov]
  • In this innovative one-page format, you can review topics such as etiology/pathophysiology, differential diagnosis, presentation, diagnosis/evaluation, treatment options, and prognosis/complications for 126 topics.[books.google.com]
  • Other proposed etiologies have included congenital müllerian anomalies, deficiencies in cervical collagen and elastin, and in utero exposure to diethylstilbestrol.[doi.org]

Epidemiology

  • This retrospective study was aimed to review epidemiology, management and outcome of cervical incompetence in Ramathibodi Hospital, Mahidol University, Thailand, from 1982 to 1997.[ncbi.nlm.nih.gov]
  • REFERENCES Harlap and Davies, "Late Sequelae of Induced Abortion: Complications and Outcome of Pregnancy and Labor", American Journal of Epidemiology (1975), vol.102,no.3.[life.org.nz]
  • Department of Epidemiology and Health Services Evaluation, Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva Israel[dx.doi.org]
  • To date, no definitive epidemiologic studies have proved that cervical insufficiency is more frequent in women exposed to diethylstilbestrol than in comparable control subjects. There are no randomized trials of cerclage in these patients.[aafp.org]
Sex distribution
Age distribution

Pathophysiology

  • A limited understanding of the pathophysiology of premature labor, difficulty of making the diagnosis, the low predictive value of the known risk factors, and the lack of effective . . . Sabrina D. Craigo, M.D.[nejm.org]
  • In this innovative one-page format, you can review topics such as etiology/pathophysiology, differential diagnosis, presentation, diagnosis/evaluation, treatment options, and prognosis/complications for 126 topics.[books.google.com]
  • Controversy exists in the medical literature pertaining to issues of pathophysiology, screening, diagnosis, and management of cervical insufficiency.[ncbi.nlm.nih.gov]
  • The pathophysiology of cervical insufficiency is still poorly understood.[doi.org]

Prevention

  • To facilitate the comparison of studies of CI, the authors suggest a nomenclature reflecting the different stages of prevention: primary, secondary, and tertiary transvaginal cervical cerclage.[ncbi.nlm.nih.gov]
  • Abstract Cervical incompetence is often associated with mid trimester pregnancy losses and preterm labour. cervical cerclage to prevent miscarriage and preterm labour is practiced world wide.[ncbi.nlm.nih.gov]
  • The prevention is to avoid any procedure which can cause cervical trauma leading to cervical incompetence.[ncbi.nlm.nih.gov]
  • Surgical treatment of cervical incompetence to prevent early abortion or premature labour has been accepted since Shirodkar introduced his operation in 1955.[ncbi.nlm.nih.gov]
  • "Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone". American Journal of Obstetrics & Gynecology.[en.wikipedia.org]

References

Article

  1. Lotgering FK. Clinical aspects of cervical insufficiency. BMC Pregnancy Childbirth. 2007;7(Suppl 1):S17.
  2. Chandiramani M, Shennan AH. Cervical insufficiency: prediction, diagnosis and prevention. The Obstetrician & Gynaecologist, 2008;10:99–106.
  3. Anum EA, Brown HL, Strauss JF. Health disparities in risk for cervical insufficiency. Hum Reprod. 2010;25(11):2894-2900.
  4. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  5. Bánhidy F, Acs N, Puhó EH, Czeizel AE. Association of very high Hungarian rate of preterm births with cervical incompetence in pregnant women. Cent Eur J Public Health. 2010;18(1):8-15.
  6. McElrath TF. Unappreciated but not unimportant: health disparities in the risk for cervical insufficiency. Hum Reprod. 2010;25(11):2891-2893.
  7. Feigenbaum SL, Crites Y, Hararah MK, Yamamoto MP, Yang J, Lo JC. Prevalence of cervical insufficiency in polycystic ovarian syndrome. Hum Reprod. 2012;27(9):2837-2842.

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Last updated: 2019-06-28 10:51